Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 4100 East Morse Road CITVZP Lodi/95240 m <br /> D <br /> CROSS STREET M,,1a Grove Road,s 0 31 Miles W of Ste APN 059-140-09 PARCEL SIZE 7.73 ACS LAND USE APPLICATION# o <br /> m <br /> OWNER NAME Qamar Hussain PHONE N <br /> OWNER ADDRESS 4100 East Morse Road CITY/STATE/ZIP Lodi/CA/95241 <br /> CONTRACTOR West Coast Exploration PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS 1540 Roosevelt Avenue CITY/STATE/ZIP Escalon/CA/95320 <br /> SUBCONTRACTOR/CONSULTANT CTE CAL Inc. PHONE (209)543-1799 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Avenue,Suite 150 CITY/STATE/ZIP Modesto/CA/95356 <br /> LICENSE X C-57 C-61 D-09 i Other NUMBER 870761 EXPIRATION DATE 1/31/2020 <br /> BILLING PARTY: OWNER I CONTRACTOR x SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 0 Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well Replacement Well Well Alteration/Modification J Other <br /> 7 Monitoring Well(s) #of wells Soil Boring(s) *of borings x Geotechnical 1 a of borings �+ <br /> Out-Of-Service Well ! Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pump 0 Pump Replacement I.Pump Repair Raise Well CasingC /�� <br /> WELL CONSTRUCTION <br /> Drilling Method U Mud Rotary 0 Air Rotary Auger Cable Tool Push Point Other JU/ ry <br /> Proposed Well Depth ft Excavation in diameter Open Bottom 0 Gravel Pack/Gravel Sizein diame r ?o1 <br /> Conductor Casing in diameter / Conductor Casing Depth ft �J�AQUI l <br /> g <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel -1 Plastic Stainless Steel U Othe CQ <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sa NEl <br /> � A l�1] <br /> Bentonite(20%solids) Other N7AL <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP 0 Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM X48 HOUR ADVANCE NOTICE REQUIRED FOR <br /> lIN PEECTI'Q`NS-PLEASE CALL(209)953-76197 <br /> SIGNED�rv'� I y `� TITLE�V 4 vt�"^-�'S DATE <br /> S E I E I JA IT T A C IH IF ID I L O C A T I O N M A P <br /> a_AENTMU E O LY <br /> Application Accepted B to f' Area Employee ID# Vfwj�� <br /> Grout Inspection By Date PECIA Well Permit <br /> Pump Inspection ByDate WAIVER Received <br /> Soil Boring Inspection By L Date "5 / I Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Cods Info Remitted S nice Re uest# <br /> EHD43-06 61112019 WELL/PUMP PERMIT <br />